Provider Demographics
NPI:1396031407
Name:WILSON, CYNTHIA (MA, MFTI, AT)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MA, MFTI, AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 W VIENTO ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOUSE
Mailing Address - State:CA
Mailing Address - Zip Code:95391-2064
Mailing Address - Country:US
Mailing Address - Phone:707-332-2349
Mailing Address - Fax:
Practice Address - Street 1:955 W CENTER ST
Practice Address - Street 2:12-B
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-7300
Practice Address - Country:US
Practice Address - Phone:209-852-6916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-27
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA66437106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor